Asthma and breathing pathomechanics: The effects of mouth breathing and hyperventilation on asthmatic symptoms.

Arguably the first and last action we all take in this life, the very act of breathing underscores our every moment, movement and effort. For many of us breathing sits as an unconscious action, often taken for granted until we have to hold it or have it cut off in an emergency event. For some, breathing is harnessed as a source of athletic power, or a tool to find focus or relaxation. For others still, breathing is a chore, a labor, a source of apprehension.

Such can be the case in those with asthma.

Effecting an estimated 8% of the American population alone, and 300 million worldwide (1), asthma is described in the medical literature as “A chronic disease that involves inflammation of the pulmonary airways and bronchial hyper responsiveness that results in lower airway obstruction that is usually reversible”(2). Clinically it is expressed as coughing, wheezing, shortness of breath and/or difficulty breathing with varying severities. Coughs are sometimes dry and unproductive, and other times a great deal of mucous is built up in the airways, further leading to airway obstruction.

Although any activity that challenges the respiratory system can be aggravating to an individual with asthma, particularly in the case of exercise induced asthma, symptoms can be present at rest as well. It is well known that asthma symptoms can often also be exacerbated at night, preventing effective sleep (3, 4, 5). This is termed nocturnal asthma, and can be often quite debilitating to the individuals over all health, as it is known that sleep deprivation is associated with deficits in memory and attention (6), increased risk of cardiovascular disease and diabetes (7), as well as an overall increased risk of morbidity and mortality (7).

Left unmanaged, asthma can contribute to significant declines in health, and even lead to an acute asthma-attack, a potentially fatal event. Thankfully modern medicine has improved enough in the last century, and the incidence of death due to an acute asthma attack has decreased. However, it continues to be a condition that contributes to a lower quality of life in many.

In some ways, modern medicine can keep you alive, but it cannot keep you well.

Modern medical management has two general approaches to treat the symptoms of asthma; via Bronchodilators and Corticosteroids. Acutely a bronchodilator is used to reduce or prevent broncospasm and widen the airway, and over the long term inhaled corticosteroids are used to decrease the bodies local inflammatory reaction of the airways. Other additional medications are used at times to further decrease the bodies inflammatory response, but these are the mainstay. The frequency of medication use is based on the severity of their symptoms, with many asthmatics taking these medications daily, sometimes more.

But why are asthmatics airways so inflamed and reactive to begin with? In short, western medicine does not really know. While the origin of the disease is unknown, what is known are the many potential irritants to asthma, and they include; cold air, exercise, upper respiratory infection, cigarette smoke, acid reflux and stress (2).

Now take note as to what many these things have in common; something in the local air is aggravating to asthmatics airways, more so than to non-asthmatics.


It is dangerous to use the terms always and never, so I will favor in this article often and typicallyOften individuals diagnosed with asthma have the tendency to mouth breath and hyperventilate. Typically this significantly effects their symptoms and the severity of their condition.



There are two routes we can use to transport air in and out of our lungs; the mouth and the nose. Although it is not the larger of the two, it seems that nasal breathing, particularly inhaling nasally is most often preferable.

Not just an ever unique fixture on the front of our faces, the nose has important contributions to our respiratory system.  Most significantly the nose functions to warm, filter and humidify the inspired air prior to being inhaled into the lungs (8). So impressive is the humidifying ability of the nose, that it not only provides an estimated 90% of the air-conditioning needs of the respiratory system, but if air is exhaled through the nose it can recover up to 33% of the heat and moisture (9).

Essentially, the nose acts as our built in air conditioner, filter, purifier and humidifier.

It does this via forcing the air over and around folds of tissue within the nasal cavity, called turbinates. This increases the surface area the air moves along, providing increased contact with the inspired air. The internal surface of the nasal cavity is lined with a layer of mucous, which functions to trap microbes, particles and airborne pollutants (10). Essentially, the nasal cavity serves as the first line of defense for our respiratory system. If there is something in the air that the body does not like, it can sneeze it out. In the case of asthma, this is preferable to the chronic cough that many experience, as mouth breathing cannot duplicate this eloquent air conditioning process.

This may be why unmanaged upper respiratory issues (i.e. rhinitis, sinusitis) is so heavily associated with poorer functions of asthma (11).

It has been recognized that the inhalation of cold, dry air is associated with increased risk of exercise induced asthma (EIA) (12), however recognition of mouth breathing as an aggravating factor is not uniformly present in most authorities recommendations. This is despite the evidence that is available. Asthmatics have been observed to mouth breathe more than non-asthmatics (13), and enforced oral breathing has been observed to cause a decrease in lung function in mild asthmatics, and even initiating asthma symptoms in some (14).

Furthermore, a study in 1981 looked at the effects of nasal and mouth breathing on individuals with and without EIA (15). The researchers had individuals run on level ground for 6 minutes two separate times; once with the nose clipped and once with the mouth closed. Lung function was measured before and after, and across the board, for both non-asthmatics and those with EIA, the bronchoconstrictive response was markedly reduced during the runs where nasal breathing was taken when compared to the response to oral breathing. Nasal breathing allowed for improved exercise tolerance.

The positive effects of nasal breathing on asthma has also been documented in cases of nocturnal asthmatic symptoms. Researchers looked at the effects of a device that dilates the nasal cavities, and studied its effects on night time asthmatic symptoms in 15 subjects with nocturnal asthma (16). Every other night for 10 nights the individuals wore the nasal dilator, and in the morning self reported whether or not they had awoken from asthma during the night, or if they needed to take asthma medication. When the nasal dilator was used the individuals woke up 17 out of 75 nights, as opposed to 32 of the 75 nights. Of the 15 subjects, 12 reported reduced nocturnal asthma, and 7 of them reported a decreased need for night time use of asthma medication.

In addition to conditioning inspired air, nasal breathing also provides a resistance to respiration that is twice that of an open mouth (17), and this appears to have several benefits. First, nasal breathing increases the total volume of air moving in and out of the lungs (17), and is associated with an increase in arterial oxygen and CO2 levels (17) (the significance of this will be reviewed further on as hyperventilation is delved into). In fact, nasal breathing during exercise has been shown to more efficiently exchange O2 and CO2 than mouth breathing(18). Lastly, the increased resistance to airflow via nasal breathing also increases the rate of exhalation (19), and increasing the exhalation phase of respiration is recognized to improve the bodies relaxation response (20), which is preferable when short of breath. Perhaps it is this increased air resistance that is perceived by those in respiratory distress, which may motivate them to switch to mouth breathing in order to ease the effort. It is here that the association between asthma and panic disorders/anxiety symptoms cannot be overlooked (21), and the individual needs to be taught to recognize that although nasal breathing may be more difficult in a moment of respiratory distress, it will help the body calm down.

It is useful to note that nasal breathing has other contributions beyond the filtering, warming and humidification of inspired air, particularly in terms of cognition. Nasal and mouth breathing are associated with changes in cognitive functions in surprisingly vast ways. Increased airflow through the right nasal passage is correlated with left brain activity and enhanced verbal performance, while increased airflow through the left nostril is associated with increased right brain activity and enhanced spatial performance (22).

Conversely mouth breathing has been associated with poorer working memory, reading comprehension, arithmetic skills and lower academic achievement in school children (23). In fact, mouth breathing is more associated with attention defecit hyperactivity disorder (ADHD) than nasal breathing (24), and is also associated with increased blood flow and oxygen load to the prefrontal cortex (the area of be brain that functions in pre-planning of actions). The effects of mouth breathing on ADHD may also be associated with increased oxygen consumption in general. The thought that too much oxygen could be a problem is a surprising one for some. Think of a hamster on a wheel and it would not be far off.

As a last note before moving on the problems with the volume and pace of respiration (hyperventilation), it is worth noting the contributions that mouth breathing has on facial development and postural habits. In short, mouth breathing is associated with, and likely causes dental/jaw deformities(25), forward head postures and elevated shoulder blades (26, 27). In fact, it has actually been shown that dental and facial abnormalities are more present in and related to simply having asthma (28). Thankfully, our body is always adapting, and changes to appearances can be made for the better if nasal breathing is adopted (29).

So, not only does nasal breathing seem to help you respire and think better, but it also seems to help you look better.

Change to our present situations can often be made, but at times it requires a strong will combined with an active effort. In the case of asthma, it is not only a change in the habitual method of inspiration that is needed, but a change in the rate and volume of air respired in general.


Hyperventilation is a pattern of excessive breathing where the size and rate of respiration is more than the current metabolic needs of the body (10). Essentially, you breathe more than you need. This can be very problematic, and often times unconsciously habitual, with its causes complex and multifactoral.

To best understand how hyperventilation is so problematic, it is good to first look at what normal, ideal breathing is. The cells of our body require oxygen (02) for fuel, and are constantly pumping out carbon dioxide (C02) as waste. Respiration acts to constantly exchange these gases, and is an amazingly fine-tuned process that is able to precisely adjust in order to the meet the current metabolic demands of our body. There is an acceptable and necessary amount of CO2 that can be present in our blood, and our body is very sensitive to its build up. Maintaining a precise range of 02 and CO2 in our blood stream is necessary to maintaining a safe pH, and adjusting our respiratory rate and volume is our bodies most effective method to accomplish this (30).

The pH scale ranges from 1 to 14, with 1 being the most acidic, 14 the most alkaline and 7 the neutral middle. Our bodies ideal pH is between 7.35 and 7.45, with fluctuations outside  of this range resulting in severe problems, including coma and death. The acidity of our blood is determined by the amount of CO2 present in it, and this is where the function of respiration comes in. C02 is analogous to the exhaust from our cellular engines, and like any engine the exhaust needs to be removed without obstruction. Our body does this by converting CO2 to an acid (carbonic acid) which can then be exhaled. This means that our blood will steadily become more and more acidic unless we are able to sufficiently remove CO2/carbonic acid via respiration (10, 30).

In the case of hyperventilation, too much CO2 is blown off, causing the blood to become more alkaline than ideal. When hyperventilation is a severe event it results in acute respiratory alkalosis, and is often associated with many short and long term adverse effects (21). These include increased seizure activity and cerebral ischemia (decreased blood flow to the brain), as well as contributing to an acute lung injury, myocardial ischemia (heart attack), and may cause cardiac dysrhythmias (21).

The symptoms of acute hyperventilation are wide ranging and often frightening. They include the neurologic symptoms of poor concentration, memory lapses, tunnel vision, headaches or tinnitus. Increased sympathetic activity leads to tremors, sweating, clammy hands and palpitations. Upper extremity parasthesiae and numbness can be present, as well as dizziness, weakness, visual disturbances and exaggerated spinal reflexes (10).

Acute hyperventilation also effects the cardiovascular system and can result in chest pain secondary to vasoconstriction of coronary arteries. Gastrointestinal symptoms can include bloating and extreme epigastric discomfort secondary to air gulping via rapid mouth breathing. Abdominal cramps and/or diarrhea can be present due to extreme anxiety.

Now when hyperventilation is chronic, even for only a few hours, it seems that the body adjusts to low levels of CO2 via the kidneys augmenting their regulation of the bodies pH, and no pH disturbance is seen (21). In this way, when one chronically hyperventilates as their breathing habit, the body becomes used to this and accustomed to lower levels of CO2 in the blood. However, although the bodies pH is normalized, the low levels of CO2 nonetheless seems to have far reaching negative effects. As a result of this compensation, there is a much decreased tolerance to fluctuation of CO2 levels. Since one is functioning with less than ideal levels of CO2 and adapted to it, any drop in CO2 via even a deep breath (increase in O2), or rise in CO2 via increased aerobic demands from activity (or breath holding as a stress response) can cause symptoms of air hunger or frightening hyperventilation symptoms.

This is where the relationship between asthma and hyperventilation becomes tragically apparent. Asthma is defined as a chronic obstructive lung disease, where symptoms are reversible. The obstruction is due to a decreased diameter of the bronchioles which effects inhalation and exhalation. However, the challenged breathing pattern of asthmatics is not so much observed to occur with inhalation; it is observed with exhalation.

By definition, asthmatics have trouble exhaling.

This is best observed in describing the appearance of an acute asthma attack. When asthmatic symptoms reach a level where a person exists in severe respiratory distress the following typical features are present; a high respiratory rate (greater than 30 breaths per minute), high pulse rate (great than 120 bpm), audible difficulty breathing (wheezing) and dynamic hyperinflation (31). This is the extreme version of hyperventilation. Dynamic hyperinflation is when a full breath of air is inhaled, but only partially exhaled before a subsequent inhale is done. The result is that the lungs are maximally inflated with inspiration, but one never fully exhales, and as this continues the air itself becomes an obstruction to breathing. Literally you choke on your own air. If not intervened with, an asthma attack can lead to respiratory failure and death.

Now the inability to easily breathe air in and out can be an extremely frightening event, and like any frightening event our body and brain remember it well. Asthmatic symptoms can be associated with a tremendous amount of anxiety, and become a panic reaction, much like any post traumatic stress disorder. The availability of inhaled bronchodialators and corticosteroids allows for individuals with asthma to decrease their symptoms, but often once their symptoms resolve they do not always return to normal breathing rates/patterns.

Research has shown that individuals with asthma often have lower baseline CO2 levels when compared to healthy members of the population (21). A study compared 23 asymptomatic individuals with a history of asthma, and compared them to 17 individuals with no history of asthma (32). Despite the absence of current asthmatic symptoms, no clinical evidence of hyperventilation and completely normal lung function in the patients with asthma, their CO2 levels were significantly lower than the group without asthma. This suggests that although they were asymptomatic at the time, chronic hyperventilation was present.

This was also seen in a study that compared the respiratory rates and CO2 levels of mild asymptomatic asthmatics to a group that identified with hyperventilation symptoms as well as a healthy control group (33). The asymptomatic mild asthma group all reported being able to control their asthma via bronchodialators. All of the individuals in the asthmatic group had significantly higher respiratory rates and volumes, as well as significantly lower CO2 levels than the hyperventilation and healthy control group. Even asymptomatically, at rest, the asthmatics respired more than they needed.

Besides the evidence that some asthmatics may chronically hyperventilate, when compared to healthy members of the population, asthmatics have also been noted to have stronger respiratory responses to very basic challenges. These include a short lived static muscle contraction of the forearm, dynamic exercise and resistive loading (21). With all studied demands the rate and volume of respiration increased more than the healthy controls.

It may be that asthmatics airways are not only excessively reactive, but perhaps also their general response to stresses are greater than useful.

Beyond increased respiratory demands, emotional stress in of itself has been suggested as a exacerbating factor of asthmatic symptoms (34). Linked to this, chronic hyperventilation with the resultant low levels of arterial CO2 has also been shown to be present in the panic attack/anxiety population, and theorized to being a major contributor to panic symptoms (21). In fact, when compared to the general population, individuals with asthma have a significantly higher incidence of anxiety, panic disorder and agoraphobia (35, 36). The cross over between the two populations is both curious and concerning. All of us know the feeling of our heart and breath racing when we are in a fearful state, and for some unfortunate few the thought of this along is terrifying. It is tragic to recognize that the fear of being short of breath may only feed into more easily being short of breath.

As if that was not bad enough, hyperventilation in of itself is known to lead to nasal congestion (37). As the body blows off excessive CO2, there appears to be a reaction to increase nasal congestion, hypothetically as a method of decreasing respiration in order to increase the bodies CO2 levels. Allowing CO2 levels to increase via slowing ones breathing rate and volume will result in decreased congestion, but unless this is understood the individual will likely just switch to mouth breathing, worsening the whole situation.

This all seems to feed a vicious cycle with the entry point unknown. Symptoms of asthma can cause distress, anxiety and panic. Anxiety/panic can feed into a hyperventilation response. Hyperventilation leads to nasal congestion. If left unaddressed nasal congestion forces mouth breathing, and mouth breathing irritates the airways leading broncho-constriction and further asthmatic symptoms.

The hamster on the wheel runs.


It has been said before and it bears repeating; if you identify the problem, you can identify the solution.

First of all please note: none of this overrides the medical management between you and your overseeing physician. If you are reading this and have asthma, do not abruptly stop taking any medication. If you experience a notable decrease in your symptoms with taking on the following, and are considering reducing the use of your bronchodilator and/or inhaled corticosteroid, discuss this with your physician first.

With that being said, if you take nothing else away from this article, learn to do the following:

Close your mouth: Breathe through your nose, especially with inhalation. This will warm, filter and humidify the incoming air, as well as maximize the total volume of air moving in/out of your lungs.

Exhale and hold: Exhale fully, and pause longer than naturally before inhaling again. Although a deep inhalation can be useful and necessary, always focus on the exhale phase. This will prevent both hyperventilation and being in a sympathetic state (arguably one and the same). Pausing after exhalation will allow CO2 levels to build up internally and you to build tolerance to it. In turn, training exhalation will allow for CO2 levels to be appropriate for the present metabolic demands.


Beyond what has already been shown that both hyperventilation and mouth breathing aggravate asthmatic symptoms, there is direct evidence that exhilatory exercise is beneficial in reducing asthmatic symptoms.

This was most notably shown in a study that took 50 patients with mild-moderate asthma, and divided them into two equal groups, each given different activities to perform (38). Group A was given a series of specific breathing exercises where inhalation was done nasally and exhalation orally with a long, drawn out sound. They were encouraged to exhale maximally, until no further exhalation was possible. Group B was instructed to simply sit and mediate while breathing nasally. Both groups were asked to do this for 20 minutes daily for 12 weeks, with measurements of lung function taken before and after the completion of the study.

As expected, you get what you train. After 12 weeks the group that performed the prolonged exhalation exercises had significant improvements in lung functions as compared to the beginning of the trial, where as the other group showed no changes.

If you practice exhaling, you are likely to get better at it.

This has actually been indirectly observed for some time. It has long recognized that swimming is a form of exercise that is non-aggravating to even severe asthma, but the exact mechanism not understood (39).  It may be quite simple actually: you cannot swim and hyperventilate! You have to increase your exhalation time relative to inhalation in order to maintain an efficient swimming posture via your head down in the water for the majority of the activity. The result is a long, full exhale with a short efficient inhale. The important thing would be to actually continue this respiration pattern outside of the water, not merely during choice moments of exercise.


One classic characteristic of chronic hyperventilation is the urge to immediately inhale after exhalation, and this is a habit that must be retrained. Many asthmatics know the terrifying feeling of “air hunger”, and tragically manage it by immediately attempting to inhale more, only making their situations worse and perpetuated.

An approach that has long recognized this is the Buteyko Method, which advocates nasal breathing and reducing ones breathing rate and volume as a method of managing asthmatic symptoms (40). Studies have show that this approach is very helpful in reducing medication use and symptoms in individuals with asthma (41), and it has actually been endorsed as a method of asthma management by the British Thoracic Society. Essentially this approach advocates increasing ones pause time after exhalation and prior to inhalation, termed the control pause. Starting with only a few seconds, one learns to eventually exhale and avoid inhalation for up to 10, 20, even 30 seconds. Again, if you are just sitting there, you really don’t need that much air, your system has just learned to be intolerant to CO2 fluctuations. Having a long (upwards of 30 seconds) control pause is deemed as a sign of good control of asthma, and advocates of this method suggest that this will be associated with decreased symptoms..

Anecdotally I have observed this to be very helpful for folks with postural and respiratory dysfunction (arguably one and the same thing). With distress our respiration rate will often rise, and unless one learns to be aware of this it can escalate out of control, leading to unnecessary anxiety, panic and asthmatic symptoms. Again, this is where the link between our body and mind is greatly expressed, and learning to cultivate mindfulness of it is requisite for gaining management of asthma.

So take this further and not only apply it to all exercise, but ideally all daily activities. What needs to be changed are habits, and change of this kind requires intention, attention and lots of practice.

With this in mind, be attentive to your breathing habits in all the parts of your daily life. Often this requires extensive mindfulness, a skill that one may or may not have yet cultivated. Be aware of how you breath in the busy and demanding parts of your day, not just during strenuous activity/exercise. Be aware of how your stress responses in the many demanding parts of your days and weeks may drive you into mouth breathing and/or hyperventilating. Be aware of perhaps functioning in a stress response even when not necessary.

Awareness is always the first step in creating change.


Beyond being mindful of breathing habits, it is necessary that one maintains the ability to breathe nasally at any and all times. Often asthmatics will have con-committant nasal allergies, and these must be effectively managed in order to prevent asthma exacerbations (42). In fact the majority of all asthma exacerbations coincide with a respiratory viral infection, and particularly rhinovirus (common cold) (43), undoubtedly due to the congestion it breeds.

Besides adhering to basic hygiene strategies during cold seasons to avoid catching one, simple strategies such as diligently taking over the counter anti-histamine medications are often pivotal to manage allergies. The use of nasal lavage has also been reported as often helpful for those who suffer from regular sinus issues (10). At times dietary factors can play into both sinus and asthmatic issues, and addressing this can increasingly provided relief from congestive/asthmatic symptoms (10).

Beyond medication and nasal lavage, there are two other readily available methods for manually opening nasal passages; plugging and pulling. Plugging refers to plugging your nose and holding your breath after fully exhaling. Holding as long as possible will cuase CO2 levels to rise internally and your nasal passages will dilate. The subsequent breath in after holding will be less congested. The next time you are congested, try it, it works impressively well.

Pulling refers to gently lifting or tugging on the skin besides your nasal passages and sinuses, allowing one to breathe more easily nasally. If this makes a significant difference, perhaps nasal strips would be useful as one is taking on nasal breathing strategies and still congested.

It is worthwhile noting that asthma is associated not just with rhinitis but also acid reflux (42). This is the case where the aggravation to airways is coming from below, not just above via the air inspired. Looking into this may be helpful in the case of nocturnal asthma that does not entirely improve with managing allergies, medication adherence and retraining breathing patterns.


Once one has established the ability to avoid hyperventilation and favor nasal breathing, working to increase your strength and aerobic base is warranted. This means increasing your endurance, stamina, and work capacity while incorporating these two breathing approaches. Improving ones aerobic base will prevent one from falling into respiratory distress and decrease the risk of triggering a panic response.

While increasing stamina is critical, one must be mindful of how one is performing all activities. We need to perform activities in a durable/efficient manner that allows for efficient respiration and stable positions/postures to drive from.

With dynamic hyperinflation and chronic hyperventilation folks are unable to use their diaphragm as respiratory muscle, and they can become stuck posturally in a flared upright position(44). Accessory muscles in the neck and upper torso are instead habitually used to lift the ribs for inhalation, causing a great variety of problems. Management of these movement, postural and respiratory dysfunctions is beyond the scope of this article. However, in short; we need to get our heels on the ground (both), our ribs down (both), and our shoulders on our body to achieve a stable position for both our core to be strong/durable and our diaphragm to function as a respiratory muscle.

I have written briefly about this position/posture HERE.

In addition to maintaining a stable core where your diaphragm can maximally function for breath, it is crucial that one has sufficient mobility of their ribcage to allow for respiration. With inspiration the lungs need to expand circumferentially, with the ribcage being compliant enough to allow them to do so.  With chronic hyperventilation, I and other clinicians (44) often observe individuals having a poor ability to flex and rotate their thoracic spine, with a very limited ability to expand their rib cage posteriorly with respiration. Essentially they get stuck ram rod straight, and can only function with shrugged shoulders and a flared, straight spine. The result is a ribcage that expands only in the front, driving their spine further extended with every inhalation.

Crucial to teaching individuals how to both breathe and stabilize their spine is to first attain the proper positions, postures and muscular tone to do so. Often this requires physical rehabilitation with the guidance of a trained professional.

Nonetheless, here are some examples of progressive thoracic mobility, and core/scapular stabilization drills incorporating respiration. Each video is accompanied by detailed instructions for form and attention. Be sure to turn on the sound for each in order to appreciate how to perform these drills integrating durable breathing strategies.






All these drills seek to improve core stability and conditioning with durable breathing strategies. An important thing with all strenuous strength training to is incorporate a forceful exhalation. In martial arts this is known as kiai, which is the japanese term for the shout used in martial arts when performing a forceful movement. Once discredited as merely an attempt to intimidate an opponent, abdominal activation (particularly obliques) has actually been shown to markedly increase with maximal exhalation (45). Often individuals that chronically hyperventilate will hold their breath with physical challenges, using their tonic diaphragms primarily instead of abdominals for stability. This is known as the valsalva manuever, and although possibly useful in the case of competitive power lifting, it has little benefit for the vast and varying rest of life/daily demands. One must learn to be both strong and able to breathe, not one or the other.

Therefore, beyond the few drills shown above, strive to integrate core stabilization and effective breathing strategies into all regular exercise habits. Remember; the brain will always prioritize air over any quality of movement, so keep so keep air moving when straining. Learn to integrate effective breathing strategies with durable movement patterns. If you do not know what durable movement patterns are, again, this is where seeking out professional guidance is crucial.


The average resting respiratory rate is estimated to be 10-14 breaths per minute, although it can be as slow as six breaths per minute with some individuals. Since we are not burning a lot of calories when we are just statically standing, sitting or laying down, we really do not need much air to fuel ourselves. So, when at rest, one must learn to truly be at rest (as written about HERE), but when a task is hard, learn to increase respiratory rate and volume accordingly and efficiently.

At rest it is advisable to favor nasal breathing, for all of the respiratory and cognitive benefits already described. Breathing should be paced, calm and effortless, and again, no more than 10-14 breaths per minute. Once any activity becomes strenuous, increased respiration is needed, and must be adjusted to the task at hand. Below are some guidelines:

Aerobic Activity: if mild-moderate stick to nasal breathing, this will maximize lung perfusion and minimize loss of hydration. If intense, inhale through nose, exhale through mouth to further recruit abdominals. Make sure to focus on exhaling fully to avoid hyperventilation.

Anaerobic Activity:  exhalation timed with effort phase of the movement performed, through mouth to recruit abdominals. Inhale through nose on recovery. Avoid breath holding/valsalva.


At times, as in the case with rigorous exercise, one may find themselves short of breath and needing to take a moment to catch it. Two commonly taken postures to do this are “Hands on Knees” and “Hands on Head”.

A short video demonstrating these two strategies can be seen HERE.

For several reasons, the preferable posture of the two is “Hands on Knees”. First, in order for our diaphragm (our primary muscle of respiration) to function as a respirator, it needs to have a dome maintained for leverage. This is achieved via the anterior ribs being held down by abdominals, allowing the diaphragm to pull on something firm and inflate the lungs. Leaning over with your hands on your knees allows for this position and the abdominal support to occur. “Hands on Head” places one in a flared, upright position with no abdominal support.

The second reason that “Hands on Knees” is preferable is that it allows for the maximal mobility of the rib cage. The position where any joint has the greatest mobility is in neutral, and neutral for the thoracic spine/ribcage is a slight kyphosis (slight flexion).  As stated earlier, being excessively upright via “Hands on Head” does not allow the ribcage to expand fully, and if you need air in your lungs this is a problem.

Thus, if and when you are short of breath, consider taking the “Hands on Knees” posture. This creates support for diaphragmatic respiratory function and allows for maximal rib mobility, enabling one to get the greatest amount of air in and out with the least effort.

In through the nose, out through themouth, slowly and fully. Repeat until able to breathe both nasally and calmly.


Asthma is described as a chronic health condition, meaning that there is no known cure. It may be that asthmatics airways are more reactive than non-asthmatics, similar to how some folks have different food or environmental allergies, but this is largely unknown.

However, what is known is that like any allergy, asthma can be managed. By minimizing exposure to the aggravating stimuli/behaviors in combination with medication to decrease the bodies response, individuals have the potential to live very active lives. In the case of asthma, the allergy is air. Filter and condition the air by breathing through your nose. Avoid hyperventilation and focus on exhaling fully and pausing.

Modern science has offered us a great deal of insights and advances, but it will always be limited in that the answers it may unearth will be confined by the framing of the questions  asked. Modern western medicine can tend to react to the symptoms of disease via simply reducing the symptoms themselves. At times this absolutely improves well being and saves lives, but at other times this can miss addressing the underlying causes, and allow for the situation to perpetuate.

Treat only the symptoms, and the fire will be doused but not put out. Treat the cause, and often the symptoms improve on their own. Our limbs and head sit under and on the moving waters of our every breath; to be aware of its patterns and far reaching effects is something priceless. To cultivate control of it, allows for vast potential.


  1. The American Academy of Allergy, Asthma and Immunology.
  2. Fireman P “Understanding asthma pathophysiology”Allergy Asthma Proc. 2003 Mar-Apr; 24(2):79-83
  3. Storms WW, et al “Nocturnal asthma symptoms may be more prevalent than we think” J Asthma 1994; 31(4): 313-8
  4. Turner-Warwick M. “Nocturnal asthma: a study in general practice” J R Coll Gen Pract. 1989 Jun; 39(323):239-43
  5. Shigemitsu H, et al “Nocturnal asthma” Curr Opin Pulm Med. 2007 Jan; 13(1): 49-55
  6. Alhola P, Polo-Kantola P “Sleep deprivation: Impact on cognitive performance” Neuropsychiatric Disease and Treatment 2007; 3(5):553-567
  7. Mullington JM, et al “Cardiovascular, Inflammatory and Metabolic Consequences of Sleep Deprivation” Progress in Cardiovascular Diseases 2009; 51(4): 294-302
  8. Sahin-Yilmaz A, Naclerio R “Anatomy and Physiology of the Upper Airway” Proceedings of the American Thoracic Society 2011: 8(1): 31-39
  9. Elad D, et al “Air-conditioning in the human nasal cavity” Respir Physiol Neurobiol 2008 Nov; 163(1-3): 121-7
  10. Chaitow L, et al “Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach” 2nd Ed. Churchill Livingstone, 2014
  11. Cazzola M, et al “Asthma and Comorbid medical illness” Eur Respir J 2011 Jul; 38(1): 42-9
  12. Tan RA, et al “Exercise induced asthma” Sports Med. 1998 Jan; 25(1): 1-6
  13. Kairaitis K, et al “Route of breathing in patients with asthma” Chest 1999 Dec; 116(6): 1646-52
  14. Hallani M, et al “Enforce mouth breathing decreases lung function in mild asthmatics” Respirology 2008 Jun; 13(4): 553-8
  15. Mangla PK, et al “Effect of nasal and oral breathing on exercise-induced asthma” Clin Allergy 1981 Sep; 11(5): 433-9
  16. Petruson B, et al “Reduced nocturnal asthma by improving nasal breathing” Acta Otolaryngol 1996 May; 116(3):490-2
  17. Swift A, et al “Oronasal obstruction, lung volumes, and arterial oxygenation” Lancet 1988 Jan 16; 1(8577): 73-5
  18. Morton AR, et al “Comparison of maximal oxygen consumption with oral and nasal breathing” Australian Journal of Science and Medicine in Sport 1995 Sep; 27(3): 51-5
  19. Ayoub J, et al “Non-invasive quantification of diaphragm kinetics using m-mode sonography” Canadian Journal of Anaesthesia 1997 Jul; 44(7): 739-44
  20. Cappo BM, Holmes DS ” The utility of prolonged respiratory exhalation for reducing physiological and psychological arousal in non-threatening and threatening situations” Journal of Pyschosomatic Research 1984; 28(4):265-73
  21. Meuret AE, Ritz T “Hyperventilation in Panic Disorder and Asthma: Empirical Evidence and Clinical Strategies” Int J Psychophysiol 2010 Oct; 78(1): 68-79
  22. Jella S, Shannahoff-Khalsa DS “The Effects of Unilateral Forced Nostril Breathing on Cognitive Performance” International Journal of Neuroscience 2009 Jul; 73(1-2): 61-68
  23. Kuroishi RC, et al “Deficits in working memory, reading comprehension and arithmetic skills in children with mouth breathing syndrome: analytical cross-sectional study” Sao Paulo Med J 2015 Mar-Apr; 133(2): 78-83
  24. Sano M, et al “Increased oxygen load in the prefrontal cortex from mouth breathing: a vector-based near-infrared spectroscopy study” Neuroreport 2013 Dec; 24(17): 935-940
  25. Harvold EP, et al “Primate experiments on oral respiration” Am J Orthod 1981 Apr; 79(4): 359-72
  26. Harari D, et al “The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients” Laryngoscope 2010 Oct; 120(10): 2089-93
  27. Neiva PD, et al “Orientation and position of head posture, scapular and thoracic spine in mouth-breathing children” Int J Pediatr Otorhinolaryngol 2009 Feb; 73(2): 227-36
  28. Faria VC, et al “The effects of asthma on dental and facial deformities” J Asthma 2006 May; 43(4): 307-9
  29. Kerr WJ, et al “Mandibular form and position related to changed mode of breathing; A five year longitudinal study” Angle Orthod 1989; 59(2): 91-6
  30. Braun SR “Respiratory Rate and Pattern” in Clinical Methods: The History, Physical, and Laboratory Examinations 3rd Ed Boston: Butterworths; 1990. Chapter 43
  31. Papiris S, et al “Clinical Review: Severe Asthma” Critical Care 2002 Feb; 6(1): 30-44
  32. Osborne CA, et al “Hyperventilation and asymptomatic chronic asthma” Thorax 2000; 55: 1016-1022
  33. Hormbrey J, et al “CO2 response and pattern or breathing in patients with symptomatic hyperventilation, compared to asthmatic and normal subjects” Eur Respir J 1988; 1: 846-852
  34. Muramatsu Y, et al “Bronchial Asthma: Psychosomatic aspect” Journal of the Japan Medical Association 2001; 126(3): 375-377
  35. Perna G, et al “Asthma and panic attacks” Biological Psychiatry 1997 Oct; 42(7): 625-630
  36. Katon WJ, et al “The Relationship of Asthma and Anxiety Disorders” Psychosomatic Medicine 2004; 66: 349-355
  37. Bartley J “Nasal congestion and hyperventilation syndrome” Am J Rhinol 2005 Nov-Dec; 19(6): 607-11
  38. Saxena T, Saxena M “The effect of various breathing exercises (pranayama) in patients with bronchial asthma of mild to moderate severity” Int J Yoga 2009; 2(1): 22-25
  39. Wang JS, et al “The effects of a swimming intervention for children with asthma” Respirology 2009 Aug; 14(6): 838-42
  40. Mckeown, Patrick “Close your Mouth: Buteyko Breathing Clinic self help manual”2004 Buteyko Books
  41. Burgess, J et al ” Sytematic review of the effectiveness of breathing retraining in asthma management” Expert Review of Respiratory Medicine 5 2011; 789-807
  42. Cazzola M, et al “Asthma and comorbid medical illness” Eur Respir J 2011 Jul; 38(1): 42-9
  43. Johnston NW, Sears MR “Asthma exacerbations: Epidemiology” Thorax 2006 Aug; 61(8): 722-728
  45. Ishida H, et al “Maximum expiration activates the abdominal muscles during side bridge exercise” J Back Musculoskelet Rehabil 2014; 27(4): 481-4

2 thoughts on “Asthma and breathing pathomechanics: The effects of mouth breathing and hyperventilation on asthmatic symptoms.

  1. As a lifelong asthmatic now age 72 & a retired general medical practitioner I found this most helpful – my asthma has been worse recently since being a full time carer for my wife who has advanced coronary heart disease – a most insightful review of a condition that the medical profession tend to think in a one dimensional way. ie. medication

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s